Provider Demographics
NPI:1104816479
Name:LUKASIEWICZ, GAIL S (NP)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:S
Last Name:LUKASIEWICZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3355 DOUGLAS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 N MICHIGAN ST
Practice Address - Street 2:SUITE 400
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1077
Practice Address - Country:US
Practice Address - Phone:574-647-8120
Practice Address - Fax:574-647-8111
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71001252A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN257270BOtherMEDICARE PTAN
IN200411050Medicaid
INP58050Medicare UPIN